Epidemiology of major lower extremity amputations in individuals with diabetes in Austria, 2014-2017: A retrospective analysis of health insurance database

The impact of diabetes on mortality rates after lower extremity amputation

OBJECTIVE

To assess the impact of diabetes, amputation level, sex and age on mortality rates after lower extremity amputation (LEA) in Belgium, and to assess temporal trends in one-year survival rates from 2009 to 2018.

METHODS

Nationwide data on individuals who underwent minor and major LEA from 2009 to 2018 were collected. Kaplan-Meier survival curves were constructed. A Cox regression model with time-varying coefficients was used to estimate the likelihood of mortality after LEA in individuals with or without diabetes. Matched amputation-free individuals with or without diabetes were used for comparison. Time trends were analysed.

RESULTS

Amputations 41,304 were performed: 13,247 major and 28,057 minor. Five-year mortality rates in individuals with diabetes were 52% and 69% after minor and major LEA, respectively (individuals without diabetes: 45% and 63%, respectively). In the first six postoperative months, no differences in mortality rates were found between individuals with or without diabetes. Later, hazard ratios (HRs) for mortality in individuals with diabetes (compared with no diabetes) after minor LEA ranged from 1.38 to 1.52, and after major LEA from 1.35 to 1.46 (all p ≤ 0.005). Among individuals without LEA, HRs for mortality in diabetes (versus no diabetes) were systematically higher compared to the HRs for mortality in diabetes (versus no diabetes) after minor and major LEA. One-year survival rates did not change for individuals with diabetes.

CONCLUSIONS

In the first six postoperative months, mortality rates after LEA were not different between individuals with or without diabetes; later, diabetes was significantly associated with increased mortality. However, as HRs for mortality were higher in amputation-free individuals, diabetes impacts mortality less in the minor and major amputation groups relative to the comparison group of individuals without LEA.

Global trends in the incidence of hospital admissions for diabetes-related foot disease and amputations: a review of national rates in the 21st century

AIMS/HYPOTHESIS

Diabetic foot disease (DFD) is a leading cause of hospital admissions and amputations. Global trends in diabetes-related amputations have been previously reviewed, but trends in hospital admissions for multiple other DFD conditions have not. This review analysed the published incidence of hospital admissions for DFD conditions (ulceration, infection, peripheral artery disease [PAD], neuropathy) and diabetes-related amputations (minor and major) in nationally representative populations.

METHODS

PubMed and Embase were searched for peer-reviewed publications between 1 January 2001 and 5 May 2022 using the terms 'diabetes', 'DFD', 'amputation', 'incidence' and 'nation'. Search results were screened and publications reporting the incidence of hospital admissions for a DFD condition or a diabetes-related amputation among a population representative of a country were included. Key data were extracted from included publications and initial rates, end rates and relative trends over time summarised using medians (ranges).

RESULTS

Of 2527 publications identified, 71 met the eligibility criteria, reporting admission rates for 27 countries (93% high-income countries). Of the included publications, 14 reported on DFD and 66 reported on amputation (nine reported both). The median (range) incidence of admissions per 1000 person-years with diabetes was 16.3 (8.4-36.6) for DFD conditions (5.1 [1.3-7.6] for ulceration; 5.6 [3.8-9.0] for infection; 2.5 [0.9-3.1] for PAD) and 3.1 (1.4-10.3) for amputations (1.2 [0.2-4.2] for major; 1.6 [0.3-4.3] for minor). The proportions of the reported populations with decreasing, stable and increasing admission trends were 80%, 20% and 0% for DFD conditions (50%, 0% and 50% for ulceration; 50%, 17% and 33% for infection; 67%, 0% and 33% for PAD) and 80%, 7% and 13% for amputations (80%, 17% and 3% for major; 52%, 15% and 33% for minor), respectively.

CONCLUSIONS/INTERPRETATION

These findings suggest that hospital admission rates for all DFD conditions are considerably higher than those for amputations alone and, thus, the more common practice of reporting admission rates only for amputations may substantially underestimate the burden of DFD. While major amputation rates appear to be largely decreasing, this is not the case for hospital admissions for DFD conditions or minor amputation in many populations. However, true global conclusions are limited because of a lack of consistent definitions used to identify admission rates for DFD conditions and amputations, alongside a lack of data from low- and middle-income countries. We recommend that these areas are addressed in future studies.

REGISTRATION

This review was registered in the Open Science Framework database ( https://doi.org/10.17605/OSF.IO/4TZFJ ).

Global estimates of diabetes-related amputations incidence in 2010-2020: A systematic review and meta-analysis

AIMS/HYPOTHESIS

This study sought to provide up-to-date pooled global estimates of diabetes-related amputation incidence from 2010 to 2020.

METHODS

Embase and Medline databases were searched for studies reporting the incidence rate (IR) of diabetes-related amputations from 2010 to 2020. IR estimates of diabetes-related amputations with associated 95% confidence interval (CI) per 100,000 individuals with diabetes were calculated.

RESULTS

23 studies were included, reporting 505,390 diabetes-related lower extremity amputations. IR of minor amputations was 139.97 (95% CI 88.18-222.16) per 100,000 individuals with diabetes, among patients with type 1 diabetes was 148.59 (95% CI 65.00-339.68) and in type 2 diabetes was 75.53 (95% CI 29.94-190.54). IR of major amputations was 94.82 (95% CI 56.62-158.80) per 100,000 individuals with diabetes, among patients with type 1 diabetes was 100.76 (95% CI 53.71-189.01) and among type 2 diabetes was 40.58 (95% CI 11.03-149.28). There were 83.84 annual amputations (95% CI 41.67-168.65) per 100,000 women with diabetes and 178.04 (95% CI 81.16-390.55) per 100,000 men.

CONCLUSIONS

Globally, annual incidence of diabetes-related amputations from 2010 to 2020 has shown to disproportionately affect men and individuals with type 1 diabetes mellitus, although its incidence is not uniform across countries.

Diabetes-Related Lower Extremity Amputations in Romania: Patterns and Changes between 2015 and 2019

Lower extremity amputations (LEAs) are a feared complication of diabetes mellitus (DM). Here we evaluated the recent trends in DM-related LEAs in Romania. We collected data from a national database regarding minor and major LEAs performed between 2015 and 2019 in patients with DM admitted to a public hospital. Absolute numbers of LEAs were presented by year, diabetes type, sex and age; incidence rates of LEAs in the general population were also calculated. Over the study period, 40,499 LEAs were recorded nationwide (83.16% in persons with type 2 DM [T2DM]); on average, the number of LEAs increased by 5.7%/year. This trend was driven by an increased number of LEAs in patients with T2DM; in patients with type 1 DM (T1DM), LEAs decreased over the study period. In patients with T2DM, the increase in minor LEAs was more pronounced than that in major LEAs. The overall number of LEAs showed an increasing trend with age (r = 0.72), which was most pronounced in patients aged ≥70 years. Men had a higher frequency of LEAs than women, regardless of DM type. These data support renewed efforts to prevent and decrease the burden of amputations among patients with DM.

Evaluation of the new, patient-adjustable socket system Varos in the early phase of prosthetic rehabilitation: a pilot study

BACKGROUND

Current prosthetic sockets often provide limited anatomical fit, especially in patients with residual limb volume changes and fluctuations.

AIM

To address these issues, Ottobock has developed the Varos Socket, a modular socket that can be adjusted by the user. The aim of this study was to evaluate the potential benefits and acceptance of a newly designed patient-adjustable socket in transfemoral amputees in early phase of prosthetic rehabilitation.

DESIGN

A prospective A-B-A pilot study was conducted.

SETTING

The setting of the study was an Orthopedic Rehabilitation Clinic.

POPULATION

Ten patients with unilateral transfemoral amputation and recent amputation.

METHODS

All patients underwent a standard rehabilitation program with physical therapy. The outcome measures included the Comprehensive Lower-limb Amputee Socket Survey (CLASS), Score Comfort Scale (SCS), a Socket Fit Scale, frequency of falls and stumbles, perceived pain, and satisfaction.

RESULTS

The total CLASS score and three sub-scores (i.e., stability, suspension, comfort) were significantly higher with Varos socket. Significantly improved comfort and quality of socket fit were observed as measured by the Socket-Comfort-Scale and Socket-Fit-Scale and a trend towards reduced residual limb pain. 87.5% of the patients reported higher satisfaction than with the standard socket.

CONCLUSIONS

The results suggest that the Varos socket improved comfort, stability, suspension, appearance, pain, and satisfaction in transfemoral amputees during the early rehabilitation program. A larger study and a longer observation period are warranted to confirm the results of this study.

CLINICAL REHABILITATION IMPACT

Quick and easy socket fitting as well as instant adjustability by the patient bear substantial potential to improve and accelerate the rehabilitation process in the early phase after amputation.

A Divide between the Western European and the Central and Eastern European Countries in the Peripheral Vascular Field: A Narrative Review of the Literature

Thirty years after the transition period, starting from 1989, Central and Eastern European countries (CEECs), representing one-fifth of the entire European population, share many historical, societal, political, economic, and cultural characteristics. Although accumulating data on coronary heart diseases and cerebrovascular diseases support these observations, in the case of peripheral arterial disease, data are scarce. The present review attempts to summarise the shreds of data that may highlight a divide in this field between CEECs and Western European countries. Disparities in risk factors and peripheral vascular care across Europe seem to be tangible and can be seen as a signal of existing differences. Improvements in research and development and the collection and cross-border share of scientific data are essential to initiate and facilitate convergence in this field.

Sex difference for the risk of amputation in diabetic patients: A systematic review and meta-analysis

The risk of amputation is a sequelae of diabetic foot ulceration, which are significantly increased in diabetic patients and caused huge morbidly and mortality. However, whether the risk amputation in diabetic patients are differing in male and female remains inconclusive. We therefore conducted a systematic review and meta-analysis to assess the sex difference for the risk of amputation in diabetic patients. We systematically searched PubMed, EmBase, and the Cochrane library to identify eligible study from their inception up to November 2020. The diagnostic value of male patients on subsequent amputation risk were assessed by using sensitivity, specificity, positive and negative likelihood ratio (PLR and NLR), diagnostic odds ratio (DOR), and area under the receiver operating characteristic curve (AUC). Twenty-two studies recruited a total of 33,686,171 diabetic patients were selected for quantitative analysis. The risk of amputation in male diabetic patients was greater than female diabetic patients (DOR: 1.38; 95%CI: 1.13–1.70; P<0.001). The sensitivity and specificity for male diabetic patients on the risk of amputation were 0.72 (95%CI: 0.72–0.73), and 0.51 (95%CI: 0.51–0.51), respectively. Moreover, the PLR and NLR of male diabetic patients for predicting amputation were 1.13 (95%CI: 1.05–1.22), and 0.82 (0.72–0.94), respectively. Furthermore, the AUC for male diabetic patients on amputation risk was 0.56 (95%CI: 0.48–0.63). This study found male diabetic patients was associated with an increased risk of amputation than female diabetic patients, and the predictive value of sex difference on amputation risk in diabetic patients was mild.

Amputations of Lower Limb in Subjects with Diabetes Mellitus: Reasons and 30-Day Mortality

BACKGROUND

Diabetic foot is one of the leading causes of patient disability worldwide. Lower-extremity amputations (LEAs) resulting from this disease massively decrease quality of life, the function of the patient, and incur significant healthcare costs. The aim of this study was to assess trends in the number of amputations, the diagnosis at discharge, and diagnosis-related mortality after LEA procedures in a nationwide population.

METHODS

Datasets of the National Heath Fund containing information about all services within the public healthcare system in Poland, spanning the years 2010-2019, were analyzed. The source of data regarding mortality was the database of the Polish Ministry of Digital Affairs.

RESULTS

Between 2010 and 2019, the annual number of amputations in patients with diabetes increased significantly from 5,049 to 7,759 (p for trend < 0.000001). However, the number of amputations in patients with diabetes calculated as a number per 100,000 diabetics decreased significantly (p for trend < 0.0005) during this period. Amputations in patients with diabetes accounted for a majority of all amputations; the mean percentage of amputations in patients with diabetes was 68.6% of all amputations (from 61.1% in 2010 to 71.4% in 2019, p for trend < 0.0000001). The most common disease diagnosed at discharge after LEA in diabetic patients was diabetes itself. Vascular pathologies, such as soft-tissue/bone/joint infections and ulcerations, were the next most common. The 30-day mortality rate after LEA was rather high in patients with, as well as without, diabetes (depending on the cause for amputation 3.5-34% and 2.2-28.99%, respectively).

CONCLUSIONS

The number of LEA in patients with diabetes in Poland increased substantially between 2010 and 2019 along with an increasing number of diabetics. Vascular pathologies, infections, and ulcerations were the most common causes of LEA. The 30-day mortality rate after amputation was rather high and varied depending on the diagnoses at discharge.